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Figure I View along Batavias harbour canal looking north c. 1875. I n the background the roadstead. I n the foreground old buildings and a drawbridge from the days of the VOC. The overgrown area in the background to the left is the silted-up coastal area where in the 18th century the fishponds were located. [KITLV B 32911

in, but outside the walls were extensive housing quarters and in the surrounding countryside impressive country houses with beautiful drives. By the standards of those days Batavia was a large town; some zoooo people lived within its walls, another IOOOOO beyond. Europeans were but a small minority: about 5000 Company employees and zoo0 freeburghers. Batavia was ill-situated o n a low coastal plain with swamps o n either side. T h e coast also posed a problem because of the rapid silting-up of the beach. At the end of the 18th century, the Castle, which had been built on the seashore, lay more than z km inland. An evilsmelling, mangrove-overgrown mud coast stretched several km wide between town and sea. People in Batavia were fearful of this malodorous coast, because it was generally believed at the time that illness was spread by evil vapours which rose from the soil and contained miasmata, small particles carrying diseases. Contemporaries suspected the silted-up mud coast as the cause of the morbidity after 1733; this suspicion grew

stronger as the unhealthiness appeared t o be limited to an area along the coast.

T h e unhealthiness of Batavia after 1733 T h e only extant numerical data on Batavias unhealthiness are the number of Company employees who died there and the number of the so-called Christian inhabitants - European burghers, mestizoes and mardijkers (indigenous Christians) - in the Christian graveyards. These data, most of which have not been published before, are plotted in Figure 2 . Before 1733,when Batavia reputedly was a healthy town, 5 0 e 7 0 0 employees died there each year owing t o various diseases such as typhus, malaria, dysentery, beriberi and many others. After 1733 that number increased t o 2 0 0 e 3 0 0 0 employees per annum. Most victims belonged to the 5000-6000 European employees newly arriving every year, as indicated by the striking decline in the mortality rate during the

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3.500

6
C

; 3.000
a
4-

v)

5 .r
C

2.500

.C m ..; 2.000 ; .L
L :

Y
U

$ a

a l

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x
Date

Figure 2 Number of Company employees 0 and adult Christian inhabitants 0 deceased i n Batavia 111 the period 1655-1810. Sources: 1655-1714 and 1796-1807 Daily Registers of Batavia; 1714-1767 Archive Hope 8464; 1767-1795 General missives of the GG a i d Council (ARA The Hague).

Fourth Anglo-Dutch War (1780-1784): For tw o years, no new employees from Europe arrived in Batavia, and during those years there was a sharp d r o p in the number of employees who died (Figure 2). T h e dramatic mortality rate among new arrivals is unequivocally documented in the V O C ships payment books (Table I). Before 1733, only 6 % of the new arrivals in Batavia died there in the first half year; after 1733 this

Table I Mortality among newly arrived VOC soldiers in

Batavia. From the VOC ships payment books (van der Brug
1994)

In the

Date
Before 1713 After 1733

1 s t half year after arrival

In the 1st year after arrival

6 Yo 40-60%

10%

5*70%

increased t o 50% or more! This went on for two-thirds of a century; a tragic loss of life and money with grave consequences for the finances of the mighty Dutch East India Company. In the 18th century, Batavia was known as the unhealthiest town in the world and its reputation was said t o be sufficient t o deter other nations from attempting to conquer it. Figure z shows a surprising characteristic of Batavias morbidity: whereas after 1733, the mortality among Company employees steeply increased and thereafter remained a t a much higher level, the mortality among adult Christian inhabitants after 1740was at pre 1733 level and remained there during the whole unhealthy period. Descriptions in V O C documents (Mossel 1753) clearly show that the indigenous population was also badly hit in the first five years after 1733; therefore it seems reasonable t o assume that by 1740 the adult Christian inhabitants had become immune to the disease.

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T h e disease that made Batavia an unhealthy place Dysentery, malaria and typhus have always been mentioned in the literature as the causes of Batavias morbidity and mortality above the level usual until 1733. But six characteristics of the high incidence of disease which emerge from V O C documents indicate that malaria alone was the malefactor. Morbidity increased epidemically between 1733 and 1738 and remained at a high level afterwards (Figure 2 ) . Survivors became immune to the disease. This _ . . . appears from the mortality rate of the adult Christian inhabitants, which after 1740 returned to the pre 1733 ievef. The fact that among Company employees, mainly new arrivals from Europe fell victim to the disease also demonstrates that people developed resistance. More than jo% of new arrivals in Batavia died in the first half year. Survivors were sickly and weak for years afterwards. T h e illness was seasonal. Monthly mortality figures, which were preserved over long periods (Van der Brug 1994), peaked sharply in August - by far the driest month of the year - and in January and February, when rainfall was heaviest. Morbidity was geographically restricted. After 1733,Batavia was unhealthy only along the coast; the Companys documents leave no doubt about that. Before 1733, the coast was as healthy as the inland region (Paravicini 1753). Evening and night-time were dangerous. Those who spent only daylight hours in the town stayed healthy (Paravicini 1753; Raffles 1817). Of all diseases in the world malaria is the only one that can account for all six characteristics. Malaria may indeed suddenly break out epidemically and remain endemic a t a high level thereafter. Malaria is one of the diseases to which people become immune. T h e mortality rate of untreated malaria tropica for people without and resistance is 5 0 % o r higher (Van der Kaay 1994); those 50% who survive the first year suffer from malaria cachexia for years to come. Malaria is often seasonal varying with the rainfall - and mostly geographically restricted, as the female Anopheles mosquitoes that

transmit malaria return every other day to their breeding places to lay eggs. And finally: malaria is only transmitted in the evening and at night, since Anopheles bite only after sundown. Thus malaria appears to be the cause of morbidity in Batavia, although this cannot be verified by means of present-day medical diagnoses or parasitological evidence. Malaria was not new to Batavia though; many descriptions of tertian o r continual fevers (Bontius 1630) show that both vivax and falciparum malaria had been prevalent there long before 1733.T h e great morbidity after 1733 must therefore have resulted from a sham increase of malaria. This reduces the auestion from: What caused the morbidity? to: What caused the sharp increase in malaria cases after r733!

Malaria cachexia among the VOC employees in Batavia Malaria played a leading role in the history of the European expansion. Because of the extremely high mortality due to malaria among Europeans in the tropics, the expansion into Asia was greatly hampered the V O C experience in Batavia being a good example while equatorial Africa remained virrually inaccessible to Europeans until the introduction of quinine in the second half of the 19th century. Only then did the familiar image of tropical areas change - sickly, seriously weakened Europeans next to healthy indigenous people. This prequinine image is also described in the V O C documents. One report, written in 1753 by J.A. Paravicini, a merchant in the service of the VOC, stands out: According to Paravicini, all the elderly inhabitants remembered that before 1733, most Europeans, in spite of leading very irregular lives, had healthy, fresh complexions, whereas by now most people look white as ghosts and are so thin and weak as to have no resistance to the slightest disease befalling them and are thus so overcome, they have to bite the dust. (Paravicini
1753)

Paravicini also reported that most clerks in the offices were half-dead and had a ghostlike appearance; many soldiers, craftsmen and sailors in Batavia were not faring much better (Paravicini 1753). According to the many descriptions in documents and letters, most Company personnel in Batavia after 1733 were weakened, looked yellowish and unhealthy and suffered

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from waxing and waning illness. T h e symptoms resemble the chronic physical signs of malaria cachexia, which include anaemia and a peculiar sallow complexion (Manson-Bahr 1966). Another feature emerging from the V O C documents is that the employees in Batavia gradually developed a degree of tolerance against the ongoing malaria infections. Governor-General Jacob Mossel (1753) reports to the 'Heren XVII', his board of directors in the Netherlands, that new employees from Europe

... mostly have to come through several periods of illness before becoming capable of inhaling the air in this place.
suggesting new employees gradually acquired immunity to malaria, a process that would have taken 5-10 years of chronic ill-health, depending on the frequency of the malaria infections, as is the case with children growing up in areas with stable malaria. Malaria cachexia among the V O C personnel i n Batavia was widespread, indicating that the majority of the employees living there were acquiring immunity. This is not surprising, considering that most of them were relatively new - V O C employees generally served only one five-year contract in the East. This means that only old-timers, who had re-enlisted several times and lived in the unhealthy town for many years would have been fit and healthy - as did the people born and bred in Batavia (both those of indigenous and of European descent), who acquired immunity in early life. T h e grave malaria epidemic in its main settlement in Asia after 1733 seriously affected the operations of the Company. Not only did more than half of the VOC employees arriving from Europe die within a year, survivors were weakened and less fit for many years. Depending on the season, 2 ~ ~ 3 5 of the V O C soldiers, % sailors and craftsmen in Batavia were hospitalized (up from 6% before 1733), incurring severe personnel shortages and considerable expense (Van der Brug
7994).

saltwater species with breeding places in brackish waters near the seashore. Nowadays two kinds of saltwater Anopheles are found along the north coast of Java, only one of which, A. sunduicus, is an effective malaria transmitter. T h e other one, A. subpictus, is no serious vector. Most likely this was also the case in the 18th century, leaving A. sunduicus mosquitoes as the malefactors in VOC-Batavia. They have a flight range of no more than 3 km from their breeding places near the coast, which corresponds to the unhealthy area described in the documents. T h a t range was sufficient to render all of Batavia and its immediate surroundings unsafe. The question remains why the malaria transmitted by A. sundaicus mosquitoes increased so suddenly in 1733 and remained a t a high level thereafter. In the IOO years before 1733,malaria intensity had been so low that large numbers of newly arrived European V O C employees could live in Batavia without major health problems. Macdonald (1957) and Bruce-Chwatt (1980) state four possible causes, three of which can be dismissed: decreased immunity of the population by the migmtion of nonimmune people - unlikely because large numbers of nonimmune migrants had been arriving in Batavia for more than a roo years without causing an epidemic;

A sharp increase in A. sundaicus mosquitoes

The mosquitoes that made Batavia so unhealthy after

1733almost certainly belonged to the species Anopheles sundaicus. T h a t follows from the fact that morbidity was restricted to the coastal area, indicating that the mosquitoes transmitting the malaria were a
Figure 3 Measuring mosquito development in the c ~ a s t tish d of dr, vanB ~ ~ ~ ~ 8 ~ , ) , [KI'I. ~ ponds of ~~~~~j~ (flying

6jv.3r.N

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introduction of P. fulciparum, the parasite of the deadly malaria tropica - dismissed because according to contemporary sources, malaria tropica had existed in Batavia long before 1733;introduction of A. sunduicus unlikely, as this species is found all along the coasts of the Sunda Islands and can be transferred from island to island by vessels; it had undoubtedly been present in Java for thousands of years. So only Macdonalds fourth possible cause for an epidemic remains: a large and sudden increase of suitable mosquito breeding places; in this case not through temporary climatic variation, but through permanent structural change.

Breeding places of A. sundaicus in the 20th century In 1918 a physician from the Government Health Service (Van Breemen 1918) demonstrated that the rampant malaria in downtown Batavia was caused almost exclusively by A. sundaicus mosquitoes breeding in the

coastal fish ponds to the north of the town (Figure 3). Van Breemen found 10other types of Anopheles in Batavia, but these transmitted but little malaria. T h e biologist Nicolaas Hendrik Swellengrebel, a central figure in the fight against malaria in Java during the 1920s, describes the abundant saltwater fish ponds of Java (tumbaks)along the north coast as favourite breeding places of A . sunduicus (Figure 4) (Swellengrebel & Rodenwalt 1932). his day, they In were teeming with A. sundaicus larvae. Swellengrebel also described the conditions for water to be suitable as a breeding place for them: it should be brackish, almost motionless and growing algae and seaweed on the surface (essential for the protection of the delicate A. sundaicus larvae). In the tambaks on the north coast all three conditions were amply fulfilled. Saltwater fish ponds for breeding banteng, an important means of existence for the inhabitants since time immemorial, cover extensive areas along Javas north coast (Figure 6). T h e ponds are dug on flat, silted-

Figure 4 Fish pond with algae at Batavia. [KIT B 639.31.N41]

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up coastal areas and connected with the sea by small canals and sluices; they often have a vast surface area but are only half a meter deep; they were traditionally covered with algae and sea weeds to promote fish growth. Breeding sea fish in coastal fish ponds is an ancient and highly developed skill; in the 192os, all coastal fishponds were sanitized in an extensive malaria control programme by prevention of algae growth. The fact that saltwater fish ponds were proven hotbeds of A. sundaicus larvae and the cause of severe malaria in the 1920s gives rise to the question whether that was also the case in 18th-century Batavia.

mosquitoes, apart from a few isolated little creeks along the coast o r temporary seawater puddles 011the beach. I have not found solid evidence that the coastal fishponds were dug in 1733. There are, however, two indirect indications that this was indeed the case. The first one is the establishment of a Javanese settlement on the silted-up coast just prior to the start of the epidemic. The second indication are seasonal mortality peaks in JanuaryiFebruary after 1733.

Fishponds and a Javanese settlement on the coast In their resolution of 13 December 1729, the High Government gave permission to build a Javanese kumpong (native village) on the silted-up coastal area north of Batavia. T h e proposal was made by the then harbourmaster Frederik Julius Coyett. Before 1729, settlement on the coastal area had been forbidden for fear that smuggling would be even harder to control. Since breeding fish in saltwater ponds on coastal mud flats had been an important means of existence since ancient times along Javas north coast, it is perfectly conceivable that the inhabitants of the new kampong started digging fishponds in 1729. Saltwater fishponds take several years to construct and - admittedly this is speculative - the villagers must have begun to use the ponds in 1733. Also speculative: Coyett could not have expected that his ill-fated proposal would end in disaster for himself. H e died in 1736 during the August malaria peak (see below), shortly after being promoted to the prestigious position of Councillor of India. Coyett was one of the 16 High Government members ( 2 GovernorGenerals, 4 Councillors and 10 Extraordinary Councillors) who died in Batavia in the first five years after the malaria epidemic broke out in 1733. In the course of the 18th century, the fish ponds to the north of the town were extended as the coast quickly silted up - on Reimers map of 1788 they stretch as far as the sea. This extension may well have been the reason why Batavia steadily became unhealthier during the 18th century (Figure 2 ) . Contemporaries did not think the coastal fish ponds posed a threat. In a treatise on Batavia, Reimer even calls the ponds beneficial to health as they never fell dry even in the driest of seasons which diminishes and remedies the unhealthy vapours [and miasmata] which might otherwise rise from this area. Reimer even proposes the digging of more ponds to make the town healthier; a proposal repeated in 1850 by

Fishponds on Batavias coast in the 18th century

VOC documents d o in fact mention coastal fish ponds north of Batavia in the 18th century. At first, solid evidence was hard to find, for fish ponds are not mentioned in the extensive literature about VOCBatavia and hardly ever in Company documents. Nor are they to be found on the many published 18th century maps and plans of the town and its surroundings. Nevertheless, an extensive complex of brackish fish ponds did exist in those days to the north of the town and adjacent to the town walls, as stated in two documents in the General Archives in T h e Hague. T h e first is an unpublished military map of the defensive works of Batavia (Reimer 1788). O n this map Reimer drew a vast complex of fish ponds on the siltedup coast to the north of the town; he probably did so because he considered the complex of strategic importance. H e called these water gardens small ponds where the indigenous breed fish (Figure 5 ) . T h e complex was huge; in 1788 covering an area of 0.8 by 1.0 kilometres - about half the area of the walled-in part of the town. T h e second proof of fish ponds north of VOC-Batavia is contained in a report o n how to defend Batavia (Berg 1752). T h e author, a military engineer like Reimer, remarks that the many fish ponds situated on the coastal area to the north of the town render enemy attack from the sea extremely difficult. This leads to the conclusion that the 18th-century coastal fishponds were the cause of Batavias severe morbidity after 1733. There is n o indication on the maps, nor in documents of Batavia, of other water surfaces meeting Schwellengrebels three conditions of breeding places for A. sundaicus

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Figure 5 Part of a map of the defensive works of Batavia by C.F. Reimer 1788. In the upper half of the chart the city walls and the

Castle of Batavia are depicted. In the lower right part the fish pond complex can be seen. At the bottom of the chart, north of the town, is the Java sea. The top of rhe chart is south. [ARA, V E L - X I ~ ~ ]

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Figure 6 Fishing in the bandeng ponds Pulu Ikan at Batavia. [KIT B 6jq.rr.N38]

a commission investigating Batavia's morbidity (Van der Brug 1994).

Mortality peaks
Contemporaries already linked the morbidity after 1733 with the rainfall in Batavia, abundant from October through March, and far less so from April through September. They describe the rampant fevers in August and the salubrity the rains brought when the wet season started. Then, in JanuaryiFebruary, morbidity peaked again, although not every year. These descriptions are in line with monthly mortality figures of V O C employees in Batavia's Day Register, which show sharp peaks in August and JanuaryiFebruary. Since August (with only 30 mm rain) is by far the driest month of the year, and JanuaryiFebruary (with on average 300 m m rain each)

by far the wettest, the peaks suggest increased malaria in those months, as malaria is often related to the rainfall. Investigations in saltwater fishponds in the 20th century (Takken 1990) have shown that rainfall and the presence of algae in ponds are the two decisive factors in larvae development and mosquito production. Thus malaria peaked in the dry month of August because then the sensitive A. sundaicus larvae were least damaged by the tropical downpours for which Batavia is known. By the same reasoning one would expect the mortality in the wettest months to be a t a low. But instead there was a peak in most years. Perhaps the extremely heavy rains in JanuaryiFebruary lowered the salinity in the shallow ponds, resulting in greatly increased algae vegetation which in turn fostered mosquito-breeding by protecting the larvae. Apparently the protective effect of the increased algae more than compensated for the larvae

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damage o f the heavy rains. Thus mortality peaks in January/February may well be characteristic of malaria originating from closed and shallow coastal fish ponds. As these peaks in the mortality among V O C employees occur only after 1733,they indicate that the coastal fish ponds which Berg described in 17j 2 and Reimer drew in 1788 were put into commission in 1733. The great fluctuations in the yearly mortality among Company employees were, most likely, also the result of the varying rainfall in Batavia. These fluctuations correspond with years in which the peaks were higher or lower than usual, o r absent altogether - the August peak presumably because of unusual rainfall in that month, the JanuaryiFebruary peak because of fewer downpours than normal. Peaks in January/February not only occur in VOC data, but also in Van Breemens mortality rate of the total population of Batavia around 1918.This is an independent indication that coastal fish ponds were the cause of Batavias morbidity in the days of the Company.

Consequences of morbidity After 1733 people moved away from the town because of its persistent unhealthiness and fast decay. Anyone who could afford it left for the countryside, some kilometres south of the town; along the Molenvliet o r in places like Noordwijk, Rijswijk and Weltevreden, where houses with spacious verandas and beautiful gardens were built. T h e first to flee the town were the members of the High Government who moved to country houses as early as 1743.Activity and employment in the town decreased when wealthy Company employees and the well-to-do middle class, with their extensive households of slaves and other servants, left. Towards the end of the century the walled-in town was mostly deserted and former wealth and luxury had vanished completely. Contemporaries wrote about an impoverished and exhausted colony overcast by a sombre and despondent atmosphere. Batavias morbidity after 1733 was a disaster for the VOC. T h e high mortality among sailors in Batavia in particular was a serious threat to the navigation and trade between Asia and Holland, lifeline of the Company. T h e VOC met the loss in personnel by recruiting large numbers of extra sailors, soldiers and craftsmen in Europe for service in the East (Van der Brug 1994). Morbidity also resulted in higher expenses

and lower profits. T h e average daily occupation of the Company hospitals rose from 300 t o rooo;the average occupation in August at times increased to 1800. Hospital expenses grew nearly tenfold between 1733and 1754.Replacement of the many sick employees by indigenous and Chinese personnel led to increased costs. By far the highest expenses, however, were incurred through hiring more personnel from Europe to make up for the losses in Batavia. Altogether the VOC recruited an extra 75000 people in the Netherlands between 1733 and 1795, who - after an expensive eight-month voyage - ended up dying in Batavia shortly after arrival. Profits were lost as homeward-bound ships and precious cargo had to stay in Batavia for lack of crew. The higher expenses and the loss of profit due to the epidemic after 1733 amounted to approxjmately 1.2 m guilders annually; a very high figure in those days which exceeded the average annual result of the entire VOC (in the Netherlands and Asia) of I m guilders (Van der Brug 19941. These figures show that the historic decline of the Company after 1730 and its weak financial position on the eve of the Fourth Anglo-Dutch War (an interestbearing debt of 2 s m guilders) were, to a large extent, the result of the existence of about one square kin of coastal fish ponds north of Batavia after 1733.

T h e ruin of the VOC By the end of the Fourth Anglo-Dutch War (178o-r784), the debts of the V O C had increased to j o m guilders. After the war the Company never regained profitability and Batavia was unhealthier than ever. The financial results after 1784were disastrous - on average some 7 m guilders annual deficit - and in 1795, bankrupt the Company was taken over by the Batavian Republic (now the Netherlands). The VOCs possessions in the archipelago became the basis of the former Dutch East Indies colony.

Fish ponds and paradigms Why did the people in Batavia -the government various investigating commissions, doctors and surgeons - never suspect the fishponds as the cause of the unhealthiness? While of course they could not know about malaria parasites, Anopheles and breeding places, everyone in Batavia knew that the unhealthiness originated from the People apparently did not coast and had started in 1733.

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ask themselves what changes had taken place along the coast in that year; their thinking remained fixed on the malodorous, silted-up mud flats along the coast as the root of the evil, because the flats fitted so perfectly the prevailing paradigm that diseases were spread by miasmata in vapours rising from the soil.

References
Berg FJ (1752) Resolutions of the Governor-General of 14-3-1752, VOC 782, pp 253-256, T he General Archive of the Netherlands, the Hague. Bontius J , (ca. (1921) 1630) In Historische schetsen, een inleiding tot her vierde congres der Far Eastern Association of Tropical Medicine (ed. LSAM Von Romer) Javasche Bockhamdal, Batavia pp. 2 5 5 . Bruce-Chwatt LJ (1980) Essential malariology. William Heinemann, London, pp. 137. Manson-Bahr H (1966) Mansons tropical diseases. Saunders, London, pp. 5 5 . Macdonald G (1957) The epidemiology and control of malaria, Oxford University Press, London, pp. 45,49. Mossel J (1753) Aanmerkingen over Batavias gesteldheit. In The Archive of Nederburgh 293 VI, The General Archive of

the Netherlands, The Hague. Nederburgh SC (1794) Letter of the Commissarissen-Generaal 19-4-1794. In The General Archive of the Netherlands, The Hague. Paravicini JA (1753) Report to Governor-General J Mossel. In Geschiedenis van de cholera in Oost-lndie voor, 18x7, (ed. J Semmelingj. Utrecht 1885,359. Raffles TS (1817) The history of Java 11. Publisher? London, app. A, viii. Reimer CF (1788) Map of the defensive works of Batavia, VEL1889. The General Archive of the Netherlands, The Hague. Swellengrebel N H & Rodenwalt E (1932) Die Anophelen von Niederlundisch-Ostindien Gustav Fischer, Jena pp. 125-126. Takken W et al. (1990) Environmental measures for malaria control in Indonesia, An historical review on species sanitation, Wageningen Agric. Univ. Papers 9-7 (1990) Wageningen, pp. 101,135, 136. Van Breemen ML (1918) De verbreiding van malaria in Weltevreden en Batavia. Geneeskundig tijdschrift van Nederlundsch-lndie 58,623-661. van der Brug PH (1994) Mularia en maluise, de VOC in Batavia in de achttiende eeuru. De Bataafsche Leeuw, Amsterdam,

PP.59,103,110,149. 150, 155,163. van der Kaay H (1994) Institute of Tropical Medicine, University of Leiden. Written Communication.

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Is there a role for traditional medicine in basic health services in Africa?A plea for a community perspective
Sjaak van der Geest
Medical Anthropology Unit, University of Amsterdam, T h e Netherlands

Summary

Traditional medicine in Africa is contrasted with biomedicine. Most traditional medical theories have a social and religious character and emphasize prevention and holistic features. Traditional medical practices are usually characterized by the healers personal involvement, by secrecy and a reward system. Biomedical theory and practice show an almost opposite picture: asocial, irreligious, curative and organ-directed; professional detachment, public knowledge and - until recently - free of charge. It is suggested that local communities do not expect that basic health care will improve when traditional healers become integrated into the service. They ask instead for improvement of basic health care itself: more services with better access, more dedication and respect from doctors and nurses, more medicines and personnel. Fieldwork needs to be done at the community level to arrive a t a better understanding and assessment of the communitys opinion concerning a possible role of traditional medicine in basic health care.

keywords traditional medicine, basic health care, primary health care, cooperation, quality of care, community perspective, Africa correspondence Sjaak van der Geest, Medical Anthropology Unit, University of Amsterdam, Oudezijds Achterburgwal 185,1012 DK Amsterdam, T h e Netherlands

Introduction
The quality of modern health care services in Africa is increasingly being criticized in recent literature (Hours 1985; Van der Geest et al. 1990; Gilson 1992; Gilson et al. 1994; Booth et al. 1995). T h e consequences of structural adjustment are strongly felt in the diminishing budgets for health care. At the microlevel, the attitude and behaviour of health personnel towards patients have been singled out as problematic. Compared to local traditional healers, health workers in the basic health services are often found to show little concern and respect for patients. T h e question could be raised whether integration of traditional healers in basic health care would help to improve its quality. Since 1978 the W H O has been calling for more cooperation, even integration, of traditional medicine and biomedicine. The role of traditional medicine was viewed as an integral part of primary health care with its

basic philosophy of self-reliance. Obviously, traditional healers and traditional self-care were considered a form of self-reliance. T h e idea was inspiring and breathed the spirit of optimism of those days. However, national governments and their ministries of health, controlled by biomedical practitioners, were less enthusiastic. They did pay lip service to the W H O suggestion, created token departments of traditional medicine, but did not give the idea much chance to materialize. Green (1996) provides a useful overview of government policies, ranging from banning traditional medicine to programs for integrating it into the regular national health service, but most policies existed merely on paper to please international donors. I shall return to this intentional misunderstanding later on when discussing the multilevel perspective. In the meantime the W H O itself has - almost silently - changed its position and placed traditional medicine in the Division of Drug

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Management and Policies where it is dying a slow death (Ventevogel 1996). By now we have a library of publications advocating o r rejecting the idea of integrating traditional and biomedical services. Most authors who have contributed t o that discussion base their argument on their own assessment of the complementarity o r incompatibility of the two - o r more - medical traditions (for overviews see Bichmann 1995; Green 1996; Ventevogel 1996). Some have interviewed local healers and/or biomedical practitioners about their views o n a possible cooperation. Overall, however, their conclusions reflect their own logic. Amazingly, the question whether local communities favour an integration of traditional and modern medicine has hardly been raised, let alone investigated by medical anthropologists. This article is a plea for such research and a t the same time carries the cautious suggestion that local communities may be less enthusiastic about the idea of integration than some of its advocators assume.

African medical traditions

It has become a tradition in Africa t o refer to medical practitioners outside the realm of biomedicine as traditional healers. In the same vein, their practice and knowledge is called traditional medicine. T h e term is misleading, embarrassing and naive. It is misleading because it suggests that there is a more o r less homogeneous body of medical thought and practice which can be put together under one name. Such a body does not exist, however. If one examines the type of medical practitioners who are designated traditional, one will find an extreme diversity both in theories and practices. T h e only thing these practitioners have in common - like alternative practitioners in Europe and North America - is that they are non-biomedical. That is why the term is embarrassing. Lumping together everything which is not ours and treating it as if it were one type is a school example of ethnocentric ignorance. Finally, the term is naive because it suggests that our medical system is not traditional, meaning handed over, from generation to generation. Clearly, biomedicine is being handed over all the time, in medical schools, in hospitals, in books and articles, through conferences and the media. Biomedicine therefore is as traditional as any other medical tradition.

Another misunderstanding is brought about by the term medical system, which suggests a coherent whole of beliefs and practices. Anthropologists, however, have shown that medical ideas and practices d o not always harmoniously fit together, There is often confusion, ignorance and contradiction in what people think and d o around health and illness. To a Western-trained scientist the statements and activities of traditional healers and their clients may seem outright illogical and unsystematic. Having said this, I will nevertheless -with some embarrassment - try to make a few general observations about African traditional medicine. African medicine consists primarily of self-help. For various reasons, selfcare and self-medication are far more widely practised in African families than, for example, in my own society, the Netherlands. Self-care is not only something of peoples own choice, it often is bare necessity due to poverty o r lack of good medical facilities (Van der Geest & Hardon 1990). Home remedies and popular knowledge of herbs and other therapeutic substances take up the greater - and perhaps the better - part of African medicine. Its efficacy is publicly discussed and, for that reason, open to critique and adjustment. Popular knowledge therefore is a most valuable part of the medical tradition. It needs to be safeguarded and strengthened if we want to enhance peoples ability to cope with health problems and to improve the quality of health care. It is more difficult to speak in such general terms about the specialists in African medicine, the traditional healers. To risk overlooking their cultural diversity and t o simplify the complexity of their medical practice, I shall discuss four more o r less characteristic features of their medical theories and three features of their style of practice. Most African medical theories have a social character. The description and explanation of illness is often phrased in terms of social interaction, in particular between members of one kinship group. The origin of illness, its treatment and prevention is linked to the quality of human relationships. Jealousy, hatred and moral wrong-doing are associated with physical and mental dysphoria. Ancestors and witches are believed to play a crucial role in bringing about illness and other misfortune. Disorder in the community leads to disorder in the health condition of its members. An illness of one family member therefore is seen as an illness of the

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entire family. Finding a solution to the problem is the responsibility of the group to which the sick person belongs. T h e second feature is the religious dimension of medical reasoning. Religion permeates every aspect of human existence, including health and disease. Medical problems are often interpreted in religious terms and, conversely, religious rituals are nearly always linked to the maintenance o r restoration of well-being in the community. Many medical practitioners are also religious specialists. Healing the body while neglecting the deeper religious grounds of the problem is senseless. African medicines third characteristic will be a surprise to most readers: its orientation to prevention. There is a popular western prejudice that Africans d o not worry about the future and are little interested in preventive medicine. It is one of the most stubborn misconceptions about Africa circulating in the rest of the world. Prevention, however, is central in peoples everyday life and follows logically from their preoccupation with religious and social values. As we have seen, traditional healers concentrate on the deeper origins of illness and insist that something should be done about them to avoid a repetition of the misfortune. They provide their patients with moral and social guidelines to prevent them from catching the same illness again. T h e preventive character of traditional medicine is, however, hardly recognized by outsiders who d o not believe in the social and religious roots of illness and consider the healers suggestions irrelevant to health and illness. T h e fourth characteristic of medical theories in the African tradition is that health and illness are more comprehensive concepts than in the Western tradition. As a matter of fact, health cannot be adequately translated in many African languages. Indigenous terms closest to it comprise a much wider semantic field. They refer to the general quality of life including the conditions of animals and plants, the entire physical and social environment. Well-being o r even happiness seem better English terms to capture the meaning of traditional African medical concepts. As a consequence, the English term medicine is also a misnomer, but interestingly the term has been indigenised in many African languages and now entails much more than restoring bodily health. Medicine is any substance that can bring about a change, anywhere, anyhow. Medicines heal a sickness, catch a thief, help someone to

pass an exam, make a business prosper, kill an enemy and win someones love (Keller 1978; Whyte 1988).In the explanatory model of many African healers there is n o neatly demarcated field of physical health. Their medical perspective is holistic in the most holistic sense of the word. Interestingly, their vision is not so different from the idealistic and much criticized W H O definition of health: a state of physical, mental and social wellbeing. Three prominent, more o r less general features of the practice of traditional medicine in Africa are the healers emotional commitment in the therapeutic process, the secrecy surrounding their practice and the healers reward. Several students of traditional medicine have described the deep personal involvement of African healers in the treatment of patients. Therapeutic sessions lasting more than an hour, and continuing over a period of several months are common. T h e style of treatment also indicates the healers concern. Patients are frequently touched and their social and mental problems extensively discussed, often in the presence of their relatives. Many traditional healers consider their medical knowledge as personal property which they protect by keeping it secret. Only a few select people are allowed to know their secret, for example an apprentice who has paid for his training o r a relative who is destined to succeed the healer in the future. The secrecy may be medically legitimized: if the secrecy around a treatment is broken, the treatment loses its efficacy (Cohen 1969; Buckley 1985; Pearce 1986,1989;Van Sargent 1986, Wall 1988). T h e secrecy also has consequences for the healer-patient relationship. T h e patient knows nothing and must totally surrender to the healer (Buckley 1985; Wall 1988). A final characteristic, contrary to some popular beliefs, is that traditional healers are rewarded for their service. Their personal involvement does not imply that their work remains unrewarded. The social context of the therapeutic act requires reciprocity. In most cases the positive outcome of a treatment needs a response from the patient o r his relatives. Paying for received treatment is a sign of respect and appreciation. No payment implies no obligation, no appreciation, no relationship (Van der Geest 1992).If no reward is given, the patient runs the risk of falling sick again. Like the concept of secrecy, the reward too has been built into

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medical theory. The payment contributes to the efficacy of the treatment.

The imported tradition

The imported biomedical system is in many respects the opposite of the above described indigenous tradition. T h e religious dimension is totally absent and the social dimension only plays a marginal role. In European history, biomedicine made its great advances after it had isolated the human body from its wider context and was able to concentrate on technical failures of the bodymachine. Its great achievements were in the field of curative medicine while prevention received far less attention. Biomedicine has an uneasy relationship with all medical traditions which hold a more holistic view of

human health and disease; the African traditions beinga

case in point. It is no wonder that also in its practice biomedicine strongly contrasts with the African way. In the first place, biomedical doctors o r nurses usually d o not want to get personally involved in the problems of their patients but prefer to keep some distance. Anthropologists who compared biomedical with other practitioners observed that the latter devoted much more time to their patients than the former and that they were closer to their patients in their choice of words and in their behaviour. Knowledge in biomedical science and practice is, almost by definition, public. Doctors openly discuss their practice with colleagues and advice is frequently exchanged among them. Progress in biomedical science is made possible through conferences and publications in which scientists make their discoveries known to the world. T h e contrast in the reward system is perhaps less prominent, but until recently, biomedicine in government institutions was -at least nominally - free of charge in a large number of African countries. T h e absence of any form of remuneration usually confirmed the absence of a personal relationship between doctors (and nurses) and their patients. This brief contrasting picture is, however, incomplete and over-schematic. It describes the imported system in abstracto. In the actual situation of African communities, biomedical knowledge and practice are often indigenised and adjusted to local needs and expectations. Self-help, for example, continues t o be

practised in hospitals and clinics. Relatives bring herbs, pharmaceuticals and other popular remedies to patients in hospitals who use them alongside the professional treatment they receive. Visiting biomedical institutions one may discover that the religious factor has entered biomedicine. Hospitals have become favourite places for religious activities. The experience of pain and suffering invites metaphysical questions among patients and their relatives. During my own admission to a Ghanaian government hospital, some years ago, I encountered more preachers than doctors and nurses. A similar observation can be made with regard to the social factor. Relatives of patients are conspicuously present in hospitals and health centres. They occupy themselves with numerous chores such as feeding and baihingpaiients and going out to buy medicines for them. It would be difficult for hospitals and health centres to function without the assistance of those relatives. It is true that the social factor has not entered the doctors aetiology and diagnosis, as is the case in the traditional setting, but social relationships d o play a crucial role in the therapeutic activities in biomedical institutions. As far as the other two characteristics are concerned, the emphasis on curative and organorientated medicine, the indigenization and transformation of biomedicine i s less prominent. T h e impersonal and unconcerned attitude of biomedical doctors and nurses t o their patients may apply to the majority of cases, but there are significant exceptions. When there is a family o r other relationship between health worker and patient, one may witness a totally different therapeutic encounter. The health worker will show concern and affection and spend a lot of time with the patient (Gilson et al. 1994). T h e openess of the doctor to colleagues and patients may be far less than one would expect from a biomedically trained person. Especially to patients, doctors (and nurses) are taciturn and secretive. Nothing is explained to them. T h e image of the all-knowing but secretive traditional healer is transposed to the biomedical physician. T h e patient just trusts him because he is the doctor. Finally, the claim that government medical services are (were) free of charge is in many cases a myth. They were only free in theory, in the official political rhetoric. In actual practice, patients had to pay a sum of money to establish a relationship with the doctor or the nurse

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to oblige himiher in order to get the treatment and medicines they desired ( Van der Geest 1982).T h e traditional concept of reciprocity was informally - and illegally - reintroduced into biomedical settings. Payment was not necessary if the doctorinurse and patient were in some way related. In those cases, payment was superfluous, since another form of reciprocity already existed. In most countries therefore the cost recovery introduced by the Bamako Initiative i s a confirmation of an existing practice rather than an innovation.

Arguments for cooperation between traditional medicine and biomedicine

T h e problems and frustrations encountered in the modern health care system seem to call for a rapprochement between biomedicine and traditional medicine. Health planners and social scientists have provided several reasons why cooperation between the two traditions should be considered an option to alleviate the present problems in health care. T h e first reason is the shortage of personnel in the biomedical sector. Training traditional healers as community health workers would be a quick and inexpensive way to fill some of the gaps in biomedical services. T h e second argument refers to the mainly rural character of the logistical problems in government health care. Doctors and nurses are reluctant to settle in rural areas and even community health workers disappear after some time to try their luck in an urban environment (Van der Geest et ul. 1990). Traditional healers are far less inclined to leave their rural community. They usually are farmers, tied to the land. Moreover they depend on the local flora and/or on local deities for their medical practice. For most of them a life in the city, where they will lose the prestige they enjoy in the home community, is not attractive. To train and install them as community health workers therefore seems a wise policy decision to improve the accessibility of basic health care in rural places. A plea for cooperation with traditional healers is also in accordance with the Primary Health Care (PHC) philosophy of self-reliance. Where possible, dependence on external services should be replaced by reliance on local resources. Traditional healers are part of the available local resources and suit the P H C concept.

T h e cultural affinity between traditional healers and their patients is a fourth reason to support grcater involvement of healers in the health care system. The fact that healers and patients share ideas about the origin, meaning and preferable treatment of illness enhances the efficacy of treatment. T h e lack of such a cultural affinity between biomedical practitioners and their patients is often blamed for the limited compliance by patients and the frustrations of doctors and nurses. T h e last reason for biomedicine to make overtures towards traditional medicine lies in the assumed unique value of the latter. The belief that African traditions contain valuable insights and therapeutic techniques which are unknown in the biomedical tradition is considered by many a sufficient grounds for closer cooperation which hopefully leads to mutual enrichment. These five arguments in favour of cooperation between the two traditions mainly reflect the outsiders perspective. They may make sense from the points of view of policy makers, idealists and social scientists, but what d o people in rural communitics think about this option? Would it be attractive to them if traditional healers were included in the basic health services? Would a dose of traditional medicine enhance the quality of health care to them? These questions are not easily answered because little is known about community perspectives on traditional medicine.

A multilevel perspective
Health polIcy is usually conceived and pushed by discussions on the level of national ministries and supranational organizations, where the interests and ideas of the local population hardly get through. Moreover, health planners are often not prepared to listen to community demands. They are convinced that people i n the villages d o not know what is good for them or come with impossible requests. Nevertheless, suggestions for the improvement of health care which have been produced by high-level policy makcrs are often presented as plans reflecting the interests of the people directly affected by them. What is needed is a research strategy for the study and comparison of health care ideas at different levels of social organization. The multilevel perspective provides such a tool to gain an understanding o f the contrasting and conflicting views between people at different social

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levels. It brings into focus possible conflicting interests at different levels. Opposite interests give shape to conflicting ideas about health care and health care policy. The same words may be used but with very different meanings. Language thus becomes a camouflage of conflicting ideas and interests. The appreciation of traditional medicine is a good example. Different opinions are probably hiding behind general statements pledging support for the inclusion of traditional medicine in the regular health care system. In the Alma-Ata document collaboration with traditional medical practitioners was recommended in the following terms: Traditional medical practitioners and birth attendants are found in most societies. They are often part of the local community, culture and traditions, and continue t o have high social standing in many places, exerting considerable influence on local health practices. With the support of the formal health system, these indigenous practitioners can become important allies in organizing efforts to improve the health of the community. Some communities may select them as community health workers. It is therefore well worthwhile exploring the possibilities of engaging them in primary health care and of training them accordingly (WHOIUNICEF 1978). In addition, the W H O (1978) devoted a report to the integration of Western and traditional medicine. Optimism about possible cooperation between representatives of different medical cultures also predominated in a collection of articles Bannerman et al. (1983) published under the auspices of the W H O . Although some scepticism about traditional medicine still exists, the idea seems to prevail at the international level that additional training and involvement of traditional practitioners can partly fill the shortage of personnel in P H C or a t least ease it and that such practitioners will make v a h a b k community health workers. Their close relationship with fellow-villagers is seen as a guarantee of good communication. A t the national level lip service is often paid to the above-cited passage in the WHO document. Promotion of traditional medicine frequently serves the purpose of national and cultural self-awareness. In practice, however, there is hardly any example of real collaboration and exchange between modern and

traditional medicine in the framework of PHC. Health workers within the biomedical system are generally opposed to the idea of collaboration, whereas traditional practitioners are often more responsive. The latter expect an increase in prestige and income through their association with the official health care system (Green 1988; World Band 1994; Ventevogel 1996). As yet, little is known about the reaction of local population groups to the incorporation of traditional medicine into PHC. While they have long been accustomed to Western and traditional medicine being used side-by-side, they are likely to see themselves fobbed off with second rate provisions when traditional practitioners are mobilized as community health workers (Green 1988).

Community perspective
H o w d o ordinary people perceive traditional medicine and would they favour some kind of integration of traditional medicine into basic health services? I have already pointed o u t that hardly any research has been done o n this question. T h e only example of such research which comes to mind is a twin project in Ghana and Thailand (Le Grand & Wondergem 1990). Most researchers deal with the opinions of policy makers, medical doctors and traditional healers. T h e first and most appropriate answer to the above question is of course that we need proper field research at the community level. Bearing in mind the caveats expressed a t the beginning of this essay, we should reckon with considerable differences in community perspectives in different African societies. African medical traditions vary enormously and so will peoples appreciation of them. I can only speculate about community perspectives, based on rather subjective impressions and experiences in various African countries (particularly Ghana, Cameroon, Mali and Zambia) and on reading - mostly between the lines - a large number of publications and unpublished reports. T h e first impression is that on the whole people do not favour a mix of biomedical and traditional services. It has been frequently observed that people have divided their health problems between biomedical and traditional practitioners. In their view, some complaints can only be treated in the hospital o r health centre and other ones only by the local healers. Integrating the two

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traditions would not help them. As a matter of fact they have already made some kind of integration in their heads. They know where to go for what kind of health problem. T h e medical situation in Africa is indeed essentially pluralistic. Moreover, and quite rightly, they would suspect that they are being cheated with cheaper and - as they call it - second rate health care if traditional practitioners would become their basic health workers. In the present situation, they have access to traditional medicine whenever they want it and they probably prefer to keep it that way. People d o want better quality of care from biomedical doctors and nurses: more concern and respect. Anthropological research in biomedical institutions in Africa is practically nonexistent. Anthropologists, usually of western origin, were after the exotic (diviners, witchdoctors, herbalists and traditional midwives) and neglected what was familiar t o them (hospitals, clinics, doctors and nurses). Overviews of the functioning of hospitals and health centres in Africa, including the recent Better health in Africa by the World Rank (1994) only discuss problems of cost-effectiveness and limited accessibility. What is widely known, though hardly mentioned in written sources, is that the quality of care in Africa leaves much to be desired. Doctors and nurses are frequently accused of not respecting patients and lacking concern. Paradoxically, that negative judgement does not prevent people from frequenting biomedical institutions. They are well aware of their technical efficacy. Patients who make use of basic health services want their own ideas and home remedies to be taken seriously. They ask for good medicines in sufficient supply. They want the services to be more accessible to them. One could perhaps say that they ask for some of the qualities of traditional healers in their biomedical practitioners, but that does not mean that they want traditional healers to replace them. T h e biomedical tradition has become an integral part of local community life and people d o not want to lose it. They rather ask for more of it: more and better medicines, more health workers, more facilities. It is significant that people in Ghana and Thailand were not very enthusiastic about the idea of introducing traditional herbs into modern health facilities. To them, herbs were out of place in the setting of a health centre (Le Grand & Wondergem 1990). h e authors, however, T recommend the promotion of herbal medicine by

biomedical workers. They argue that integrating herbs into basic health care would be far preferable to the integration of traditional healers. As we have seen before, herbs which are commonly and widely used have to some extent proved their efficacy. I t is uncertain, however, that the practices of secretive healers are equally effective. Some healers claim that the therapeutic efficacy of a plant does not lie in the plant itself, but that they give the plant its medicinal power through a ritual act such as a prayer o r a blessing. Yoruba healers in Nigeria, for instance, awake the power of a plant by incantations. The incantation is not directed to the patient (who cannot understand it) but to the medicine (Buckley 1985). Without the magical formula the medicine would not work. Similarly, in Burundi, for 80% of herbs used by specialist healers, the efficacy is added to the herb by the healer. T h e healers emphasize that it does not matter which herb they use; the only thing which counts is that they make it into a medicine (Baerts & Lehmann 1993). H o w they d o this is a well-kept secret. Mallart Guimera (1977), who did research in South Cameroon, discovered a disquieting lack of consensus among healers as to which herb was effective against which medical problem. Their completely different perspectives on efficacy would make their cooperation with biomedical practitioners extremely problematic. Moreover, the motives of healers who d o join the public health care system are sometimes opposed to those of health planners. Green (1988) reports that a survey among healers in Swaziland showed that:

... if they were to choose which aspects of Western medicine they could learn about, they would choose X-ray technology, blood transfusions and injections of antibiotics.
Healers hope to raise their social prestige and increase their income by learning the mysteries of modern medical science and sharing the prestige and income of biomedical practitioners. It is no wonder that many of their biomedical colleagues have their reservations: A plan to develop healers as promotors and distributors of packaged oral rehydration salts was defeated by physicians and health officials who felt traditional healers could not be trusted with modern medicine. (Green 1988)

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Conclusion
My - admittedly hypothetical - impression is that most communities d o not expect improvements in basic health care when traditional healers become integrated into che service. They ask instead for improvement of basic health care itself: more, and more accessible services, mote dedication and respect from doctors and nurses, more medicines and personnel. Medicines used in traditional self-care also deserve more attention from policy makers. Most importantly, fieldwork needs to research at the community level to arrive a t a better understanding and assessment of the communitys opinion concerning a possible role of traditional medicine in basic health care. Suggestions to integrate traditional medicine into basic health care are insufficiently founded on the views and preferences of those who would be most directly involvcd in such a policy. Pleas for the integration of traditional and modern medicine seem to be mostly inspired by romantic - and simplistic - ideas concerning traditional medicine or by economy motives. Medical anthropologists should assess the rationality and feasibility of such recommendations by studying the views of people in the community.

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health promotion: A comparative study of herbal drugs in primary health care. Royal Tropical Institute, Amsterdam. Mallart Guimera L (1977) Medecine et pharmacopee Evuzok.
Laboratoire dEthnologie et de Sociologie Comparative, Nanterre. Pearce T (1986) Professional interests and the creation of medical knowledge in Nigeria. In The professionalisation of African medicine (Ed. by by M Lasr M & GL Chavanduka) Manchester University Press, Manchester, pp. 237-258. Peatce T (1989) The assessment of diviners and their knowledge by civil servants in Southwestern Nigeria. Social Science and Medicine. 28,917-924. Sargent C (1986) Prospects for the professionalisation of indigenous midwifery in Benin. In The professionalisation of African medicine (Ed. by by M Last & GL Chavanduka) Manchester [Jniversity Press, Manchester, pp. 137-150. Van der Geest S (1982) The efficiency of inefficiency: Medicine distribution in South Cameroon. Social Science and Medicine 16, 2145-2153. Van der Geest S (1992) Is paying for health care culturally acceptable in Sub-Saharan Africa? Money and tradition. Social Science and Medicine 34,667-673. Van der Geest S & Van Hardon A (1990) Self-medication in developing countries. Journal of Social and Administratioe Pharmacy 7,199-204. Van der Geest S, Speckmann J D & Streefland PH (1990) Primary Health Care in a multilevel perspective: Towards a research agenda. Social Science and Medicine 30,1025-1034. Ventevogel P (1996) Whitemun k things. Training and detrarning healers in Ghana. Her Spinhuis, Amsterdam. Wall LL (1988) Hausa medicine. Illness and well-being in a West African culture. Duke University Press, Durham. WHO (1978) The promotion and development of traditional medicine. TRS 622. WHO, Geneva.

Acknowledgements
Parts of this paper were used in a keynote address at the European Conference of Tropical Medicine in Hamburg, October 1995.

References
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